Nokea
To ensure safety for a hospitalized blind client, the nurse should:
- A. Require that the client has a sitter for each shift.
- B. Require that the client stays in bed until the nurse can assist.
- C. Orient the client to the room environment.
- D. Keep the side rails up when the client is alone.
Correct Answer: C
Rationale: Orienting the client to the room environment promotes safety by helping the blind client navigate the space independently and reduce the risk of falls.
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The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
- A. Decreased blood flow
- B. Increased blood flow
- C. Slow blood flow
- D. Thrombus formation
Correct Answer: A
Rationale: The hallmark of PVD is decreased blood flow due to arterial narrowing from atherosclerosis or other occlusive processes. This reduced flow causes ischemia, leading to claudication (pain during walking) that is relieved by rest. Increased or slow blood flow and thrombus formation are not the primary characteristics.
The nurse should assess a client with Addison's disease for which of the following?
- A. Weight gain.
- B. Orthostatic hypotension.
- C. Lethargy.
- D. Muscle spasms.
Correct Answer: B
Rationale: Orthostatic hypotension is common in Addison's disease due to aldosterone deficiency, causing sodium and fluid loss.
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
- A. Appearance of cyanosis
- B. Radial pulse
- C. SpO2 of the affected fingers
- D. Blood pressure
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.
A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls.
- A. The client receiving chemotherapy who complains of a loss of appetite.
- B. The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program.
- C. The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence.
- D. The client with colon cancer who has questions about a high-fiber diet.
Correct Answer: C,A,B,D
Rationale: Urinary incontinence (C) may indicate a serious complication like spinal cord compression, requiring immediate attention. Loss of appetite (A) during chemotherapy can lead to malnutrition, followed by the mastectomy client's support needs (B), and then dietary questions (D).
A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?
- A. To support the lower portion of the leg.
- B. To support the thigh and upper leg.
- C. To allow attachment of the skeletal pin.
- D. To prevent flexion deformities in the ankle and foot.
Correct Answer: A
Rationale: The Pearson attachment supports the lower leg, maintaining alignment in balanced suspension traction.